Pelvic congestion syndrome 

Pelvic congestion syndrome (PCS) is a chronic condition characterized by pelvic pain due to venous insufficiency, often caused by incompetent ovarian and pelvic veins. It is a frequent but often misdiagnosed cause of chronic pelvic pain in women of reproductive age.

Etiology

• Pelvic Venous Insufficiency: Incompetency of the internal iliac vein, ovarian vein, or both.
• Ovarian Varices: About 10% of women have ovarian varices, and 60% of these women may develop PCS.
• Multifactorial Causes: Hormonal influences, valve insufficiency, venous obstruction, and the release of pain-inducing substances due to venous dilation and stasis.
• Usually age 35-40yo with 3-4 children

Epidemiology

• Population Affected: Primarily premenopausal, multiparous women.
• Prevalence: Found in about 30% of women with chronic pelvic pain.

Pathophysiology

• Venous Dilation: Abnormal dilation of interlinked venous channels of the internal iliac veins and ovarian veins.
• Valve Incompetency: Congenital absence or incompetency of venous valves, more commonly seen on the left side.
• Physiological Changes: Increased pelvic vein capacity during pregnancy, leading to retrograde blood flow and valve incompetency.
• Secondary Causes: External compression from conditions such as nutcracker syndrome (left renal vein entrapment) and May-Thurner syndrome.

History and Physical

• Symptoms:
  • Dull ache or heaviness in the pelvis, lasting 3-6 months, often worse with standing, walking, during menstruation, and post-coital.
  • Unilateral, increased with walking/standing, relief with lying down, deep dyspareunia, postcoital aching
• Physical Examination: Uterine tenderness, ovarian tenderness, and cervical motion tenderness on bimanual examination.

Evaluation

• Pelvic Ultrasound: First-line imaging to evaluate pelvic anatomy, ovarian changes, and venous dilation.
• Color-Doppler Ultrasonography: Assesses retrograde flow, vein size, and valve incompetency.
• CT and MRI: Detailed imaging of pelvic vasculature; MRI is preferred for premenopausal women due to the absence of radiation.
• Venography: Gold standard for diagnosing pelvic congestion, identifying incompetent veins and venous reflux.
• Laparoscopy: Often used in the evaluation of chronic pelvic pain to identify underlying pathology, including pelvic congestion.

Treatment / Management

• Medical Management:
  • Gonadotropin-Releasing Hormone (GnRH) Agonists: Goserelin, danazol.
  • Hormonal Therapies: Combined oral contraceptives, progestins, etonogestrel implants, medroxyprogesterone acetate.
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): For pain relief.
  • Phlebotonics: To improve venous tone and reduce congestion.
• Surgical Management:
  • Ovarian Vein Ligation: Effective in 75% of cases for symptom resolution.
  • Endovascular Procedures: Minimally invasive outpatient procedures using embolization coils, glue, foam, or sclerosants to ablate incompetent veins.
  • Bilateral Salpingo-Oophorectomy and Hysterectomy: Less favorable results for PCS.

Differential Diagnosis

• Urinary Tract: Interstitial cystitis, painful bladder syndrome.
• Gastrointestinal Tract: Irritable bowel syndrome.
• Musculoskeletal Disorders: Myofascial pain, pelvic floor myalgia.
• Neurological Disorders: Pelvic neuralgia.
• Gynecological Conditions: Endometriosis, pelvic inflammatory disease.
• Mental Health Disorders: Chronic pelvic pain of psychological origin.

Prognosis

• Treatment Outcomes: Symptom resolution in 68.2%-100% of cases with medical and surgical treatment.
• Pelvic Embolization: 6% to 31.8% of patients report no significant pain relief post-procedure.

Complications

• Surgical Treatments:
  • Increased rates of recurrent (20%) or residual pelvic pain (33%).
  • Aesthetic damage and longer hospitalizations.
  • Loss of gonadal function requiring hormonal replacement.